Emergency Medicine · Year 3 · from Emergency Medicine
Case 1: Anterior STEMI with Cardiogenic Shock
Patient Demographics
- Age: 62 years
- Sex: Male
- Occupation: Construction manager
Chief Complaint
"Crushing chest pain for 45 minutes."
History of Present Illness
A 62-year-old male presents via EMS with severe substernal chest pain that began suddenly while at work. He describes the pain as "crushing" and "like an elephant sitting on my chest," radiating to his left arm and jaw. Associated with diaphoresis, nausea, and shortness of breath. Pain is 10/10 and unrelieved by rest. Risk factors include smoking (40 pack-years), hypertension, and family history of MI (father at age 55).
Initial Assessment
ESI Level: 1 - Immediate life-threatening condition
Vital Signs:
- Heart rate: 110 bpm, regular
- Blood pressure: 88/54 mmHg
- Respiratory rate: 26 breaths/min
- SpO2: 91% on room air
- Temperature: 36.8C
First Impression:
- Diaphoretic, pale, clutching chest
- Appears acutely distressed
- Speaking in short phrases
Primary Survey and Initial ECG
Door-to-ECG Time: 4 minutes
ECG Findings:
- Sinus tachycardia at 110 bpm
- ST elevation in V1-V4 (4-6mm)
- ST elevation in aVL (2mm)
- Reciprocal ST depression in II, III, aVF
- No pathological Q waves yet
Interpretation: Acute anterolateral STEMI - LAD occlusion
STEMI Time Targets
| Target | Actual | Met |
|---|---|---|
| Door-to-ECG <10 min | 4 min | Yes |
| Door-to-Cath Lab activation <10 min | 6 min | Yes |
| Door-to-Balloon <90 min | 52 min | Yes |
Management
Immediate Interventions (within 10 minutes):
- High-flow oxygen (SpO2 <94%)
- Aspirin 325mg chewed
- IV access x2
- Continuous cardiac monitoring
- 12-lead ECG with right-sided leads (V4R)
- Cath lab activated - STEMI alert
Adjunctive Therapy:
- Ticagrelor 180mg PO loading dose
- Heparin 60 units/kg bolus (max 4000 units)
- Sublingual nitroglycerin withheld (SBP <90)
- No morphine given (concern for hemodynamic effects)
Cardiogenic Shock Management:
- Norepinephrine infusion started for MAP <65
- Careful fluid challenge (250mL bolus - no improvement)
- Dobutamine added for inotropy
Cardiac Catheterization Findings
- 100% occlusion of proximal LAD
- Moderate disease in RCA (70%)
- Successful PCI with drug-eluting stent to LAD
- TIMI 3 flow restored
- IABP placed for cardiogenic shock support
Post-PCI Course
Echo (24 hours):
- EF 30% (severely reduced)
- Anterior and apical akinesis
- No mechanical complications
Hospital Course:
- Weaned off IABP day 3
- Vasopressors discontinued day 4
- Started on guideline-directed medical therapy:
- ACE inhibitor (captopril)
- Beta-blocker (metoprolol - uptitrated slowly)
- High-intensity statin (atorvastatin 80mg)
- DAPT (aspirin + ticagrelor)
- Smoking cessation counseling
- Cardiac rehabilitation referral
- ICD evaluation at 40 days post-MI
Teaching Points
- Time is muscle: Every minute of LAD occlusion causes ~1.9 million cardiomyocyte deaths
- STEMI equivalents: Recognize anterolateral pattern - reciprocal changes in inferior leads
- Cardiogenic shock management: Requires vasopressors/inotropes AND revascularization - PCI is definitive therapy
- Avoid nitroglycerin in hypotension: Check BP before and after each dose
- IABP for cardiogenic shock: Bridge to recovery or further intervention
Clinical Image
Image Description: 12-lead ECG demonstrating acute anterior STEMI with ST-segment elevation in leads V1-V4 and aVL, with reciprocal ST depression in inferior leads, consistent with proximal LAD occlusion.
Attribution: Image from Wikimedia Commons, ECG of anterior myocardial infarction. Public domain. Source: https://commons.wikimedia.org/wiki/File:AMI_anterior_ST_elevation.jpg